- Email: [email protected]
Intrathoracic Lipomas
507
INTRATHORACIC LIPOMAS tients resolution is rapid and is complete within two weeks while in others it is slow and takes several months. Still others have persistent findings even after years. The chest may remain normal following recovery but in some patients delayed changes occur. Following an interval varying from two to seven years focal nodularity may appear and progress to calcification. In these patients one sees diffusely distributed miliary type of focal fibrosis and calcification. Uusually the lesions vary from 1 to 5 mm in diameter but larger lesions have been described. COMMENT
Varicella pneumonia should ultimately prove to be one of the more frequent causes of diffuse calcific foci in the lungs. In a recent publication Brunton and Moore? surveyed 16,894 people and found 463 or 2.7 percent with a history of chickenpox in adult life. Among these there were eight patients who had diffuse calcification presumed to have been caused by chickenpox pneumonia. This reflected an incidence of 1.7 percent who underwent subsequent calcification. Since eight occurred among approximately 16,000 people in the survey they found approximately one among each 2,000 people in their general population. The average radiologist even in areas where histoplasmosis is endemic does not see more than one patient with diffuse focal calcification per thousand chests examined. It behooves him to check each of these patients to determine whether there was a history of chickenpox in adult life and if the history is positive to rule out other causes. Recently I saw such a patient and confirmed a severe case of chickenpox pneumonia 14 years earlier. This patient had negative tuberculin tests and a negative complement fixation test for histoplasmosis. Our patient was a heavy smoker prior to and after her Varicella pneumonia. Knyvettv" and his associates have raised the question of the relationship of smoking to the formation of calcification in patients who have had Varicella pneumonia. Since smoking is one of the major causes of pulmonary fibrosis it is reasonable to conjecture that the combination of the two processes would be more apt to produce calcification. The vast majority of patients described in the literature who have pulmonary calcification following chickenpox pneumonia have been smokers. It does not, however, seem necessary to have the combination. The late effects of chickenpox pneumonia on pulmonary physiology have recently been investigated by Dahlstrom and his associates" who performed pulmonary function studies on patients who had calcification following Varicella pneumonia. They found signs of increased shunt in the pulmonary circulation in many of their patients and concluded that pulmonary involvement in Varicella may be extensive enough to cause lasting though moderate impairment of respiratory function. The differential diagnosis includes many diseases. Histoplasmosis is the most frequent cause of calcification indistinguishable from those of \1aricella pneumonia. Histoplasmosis, unlike Varicella, frequently results in cal-
CHEST, VOL. 60, NO.5, NOVEMBER 1971
cification in the hilar nodes, spleen and occasionally in the liver. Tuberculosis was once thought to be a frequent cause of diffuse calcification in the lungs hut evidence in favor of miliary calcification in the lung has become less convincing in recent years and is considered extremely rare or nonexistent by many authorities. Coal miners' pneumonoconiosis results in miliary calcifications. These are usually associated with a background which has only minimal fibrosis. Schistosomiasis can cause a similar picture but is associated with cor pulmonale and esophageal varices. Other conditions which cause parenchymal calcification include Caplan's syndrome, scleroderma, amyloidosis, paragonimiasis, armillifer, metastatic neoplasm, pulmonary ossification, pulmonary alveolar microlithiasis and mitral stenosis. I am grateful to Dr. Earl B. Wert and Dr. Thomas D. Davis for their help with the pathology in this case and to Dr. Samuel Eichold for the interesting clinical history. Mrs. Norma Breazeale is C0l11111ended for her help in the preparation of this paper. ACKNOWLEDG~IENT:
REFERENCES
2 3
4 5 6 7
8
9
Mackay JB, Cairney P: Pulmonary calcification following varicella. New Zeal Med J 59:338, 453-457, 1960 Buechner HA: The differential diagnosis of miliary diseases of the lungs. Ann Intern Med 43: 1,89: Ill, 19,159 Abrahams EW, Evans C, Knyvett AF, et al: Varicella pneumonia: A possible cause of subsequent pulmonary calcification. Med J Aust 2:781-783, 1964 Knyvett AF, Stringer RE, Abrahams EW: The radiology of chickenpox lung. J Coli Radiol Aust 9:2, 134-139, 1965 Knyvett AF, Stringer RE, Abrahams EW: Pulmonary calcification following chickenpox in childhood. J Coli Radiol Aust 9:3, 224-227, 1965 Waring JJ, Neubuerger K, Ceever EF: Severe fonns of chickenpox in adults. Arch Intern Med 69:384-408, 1942 Brunton FJ, Moore ~fE: A survey of pulmonary calcification following adult chickenpox. Brit J Radiol 42: 256-2.59, 1969 Dahlstrom G, Hillerdal 0, Nordbring F, et al: Pulmonary calcifications Following Varicella and their effect on respiratory function. Scand J Resp Dis 48:249-267, 1967 Salzman, E, Lung calcifications in x-ray diagnosis. St. Louis, Charles C Thomas, 1968
Reprint requests: Dr. Raider, 1720 Spring Hill Avenue, Mobile, Alabama 36604
Intrathoracic Lipomas* Richard F. Rosenberg, .l1.D., Berta At. Rubinstein, L\t.D.,oO and Neil H. Messinger, u.o»
Two cases of thoracic lipomas are reported, one subpleural and the other both intra- and extrathoracic. Some of the more important roentgen and clinical features are stressed. Lipomas should be considered in the differential diagnosis of pleural tumors. o From
the Department of Radiology, Montefiore Hospital and Medical Center, Bronx. 00 Associate Professor of Radiology, Alhert Einstein College of Medicine. tAssistant Professor of Radiology, Albert Einstein College of Medicine.
508
ROSENBERG, RUBINSTEIN AND MESSINGER
of adipose tissue ill tIll' subpleural paT herietalpresence area was emphasized when Evunder! reported
three case-s of extrupleural fat pads seen with pneumothorax . It would seem likely, therefore, that lipomas. com mon tumors of subcutaneous tissue, should arise fairly Irequentlv in this regioll . I lowcver, a review of the literature shows that iutruthoracic lipomas are rarely encountered, particularly those of subpleural or parietal pleural origin . \\'e have encountered two such cases within the past two years, the second of which was correctly diagnosed preoperatively. CASE REPORTS CASE
I
A 14 and one-half vear-old white h"v first sOIl~ht uu-dical attention lx-cause of ft'\ 't'r , malaise, ami intennittent shaking chills of two and a half weeks ' duration . The past history was unn-markahh-. Physical exa m illation and laboratory data wr-r« unn -veulimr . Houtim- c lu -st film (Fig I) showed all ovoid dt'nsity in the left chest wall in the area of tln- 7th and Stlt inn -rcostul spaces. Oblique views of the chest and laminauruphy cleuumstrutcd th e typical extraph-urul uppeurunc«, as well as SOllie n -lutive radiolucency of th e mass . The mass was noted to lx- mobile and tilt' adjucent ribs wen- intact. At thonu-otomy, a fi x () em tumor was fouml suhph-urally at the lew I of tilt' h-It Hth rih overlapping tilt' 7th and Hth intercosta] span's at tht, posterior a xillary lim " unattachecl to the d,,'st wall. Histolouic sections revealed the pn-scnce of ruaturr- fat ('{,lis consistl'nt with lipoma.
F'(;t:IlE 2. A poorly d,·fined mass is seen on the frontal view overlying tilt' right .')th intercostal space. ( Fig .'3). It was noted to he mohil« and extrupleural in origin (Fig 4). A preoperative radiographic diagnosis of a lipoma was marie. S"hs('I1,,,'ntly tlu- putk-nt 's physician palpate-d a
This usymptumatic patient was found to han' a poorly d(,fil1( 'd mass o\'{,dying the right 4th and .')th intercostal spact·s on routine chest film (Fig 2). On left anterior oblique vii-w, tilt' mass is shown to he hOllr-glass in confiuurution
Fu.tru: I. Frontal \'iI'W showiru; r-xtruph -ural ovoid d, 'nsity in 7th .mcl Sth illtl "Tostal spac,'s.
FI(;l'IlE :3. LAO projection demonstrutr -s tlu- hour-glass configuration of tilt' I,'sion .
CHEST, VOL. 60, NO, 5, NOVEMBER 1971
509
PACEMAKER-INDUCED SUPERNORMAL A-V CONDUCTION
roentgenographic signs to help in the diagnosis of intratboracic lipoma. Gramiak and Koerner, ~ in describing two cases of subpleural lipoma, emphasized the change in the shape of the lesion with respiration . During deep inspiration , there is a Ratten ing and overall diminution in the size of the mass due to compression by expanding lung. Dolley and Brewer" noted that mediastinal lipomas transmit cardiac pulsations with an undulating motion. Heuer" noticed the lucency of the mass. Berne and Heitzman" recognized that localized pleural tumors are often pedunculated. Because of the presence of the pedicle, these tumors are mobile and, hence, marked changes in shape and density of the mass will occur Oil comparable projections. They feel that recognition of pedunculation indicates with certainty that a mass is of pleural origin and, therefore, represents the most reliable sign of a pleural tumor. Although a rare entity, lipomas should be considered in the differential diagnosis of extrapleural masses simulating pleural tumors. Its accessibility, easy removal, and benignity make for rapid, postoperative recovery and excellent prognosis. REFERESCES
2 3 FIGURE 4. Opposite oblique confirms the extra pleural location of the lesion. mass within the soft tissues of tilt' chest wall. In the physician's omct', with local anesthesia, a yellow dumbbell-shaped mass was found in tilt' soft tissues of the chest wall in tilt' region of the fourth anterolateral right rib. The origin of tht' mass was noted to he deep to tilt' intercostal muscles and endothoraclc fascia. Thoracotomy was considered necessary for tilt' total excision of the lesion. Microscopic sections of tilt' removed portion revealed the presence of mature fat cells consistent with a lipoma. DISQ.JSSIO:\,
Most intrathoracic lipomas are discovered on routine chest roentgenograms in asymptomatic patients. Symptoms generally arise when the mass exerts pressure on contiguous structures, Berne and Heitzman- emphasized that intrathoracic masses, when accompanied by fever, chills, migratory arthralgias, and clubbing of digits are likely to be pleural in origin. Despite such symptoms in our first patient, we believe that the tumor was an incidental radiologic finding. Keeley and Vana" classified mediastinal lipomas as : I) intrathoracic, those lying entirely within the thoracic cage; and 2) hour-glass thoracic lipomas, those having an intrathoracic and extrathorucic portion . Case 1 belongs to the first group while Case 2 can be classified as the hour-glass variety. Because the correct preoperative diagnosis has been made rarely, several authors have attempted to develop
CHEST, VOL. 60, NO.5, NOVEMBER 1971
4 5 6
Evander LC: Pleural fat pads. Cause of thoracic shadows . Amer Rev Tuherc S7 :4HS, HJ48 Berne AS, Heitzman ER : The roentgenologic signs of pedunculated pleural tumors. Amer J Hoentgenol Rat! Ther and Nuclear Med 87 :892, 1962 Keeley JL , Vana AJ: Collective reviews : Lipomas of nuxliastinum-1940 to 1955. Internat Ahstr Surg 103:313, 19S() Gramiak R, Koerner HJ : A roentgen diagnostic ohservation in subpleural lipoma. Amer J Hoentgenol Rat! Ther and Nuclear ~led 98 :465, 1966 Dolley FS, Brewer LA III : Diagnosis and treatment of primary intrathoracic hnnors. JA~IA 121: 1130, 1943 Heuer (;J : Thoracic lipomas. Ann Surg 98:801 ,1933
He-print requests : Dr. Neil Messinger, Monteflore Hospital Center, III East 210th Street, Bronx 10467 and ~lt ·dical
Pacemaker-Induced Supernormal Atrioventricular Conduction * Denllis V . Cokkinos, A/.D.;·· Louis L . Leatherman, ,\J. D.;t Roher! D. Leachman, .\ I.D., F.C.C.P.;: and
Robert t. Hall, M .D .§
Atrioventricular conduction occurred intermiUently in a patient paced for complete heart block produced by inferior myocardial infarction. Atrial stimuli were conducted to the ventricles only when they occurred 320 to 360 msec after the spike of the right ventricular endocardial pacemaker. This phenomenon is attributed to the production of supernormal atrioventricular conduction by the pacemaker induced beats. • From the Cardiology Section, Saint Luke's Episcopal Hospital and tilt' Texas Heart Institute, Houston , Texas. •• Fellow in Cardiology, Saint Luke's Episcopal Hospital. t Attending Cardiologist. Saint Luke's Episcopal Hospital. :Chief, Cardiology Laboratory, Saint Luke's Episcopal Hospital and Texas Heart Institute. §Chief, Cardiology Service, SI. Luke's Hospital and Medical Director, Texas Heart Institute.
INTRATHORACIC LIPOMAS tients resolution is rapid and is complete within two weeks while in others it is slow and takes several months. Still others have persistent findings even after years. The chest may remain normal following recovery but in some patients delayed changes occur. Following an interval varying from two to seven years focal nodularity may appear and progress to calcification. In these patients one sees diffusely distributed miliary type of focal fibrosis and calcification. Uusually the lesions vary from 1 to 5 mm in diameter but larger lesions have been described. COMMENT
Varicella pneumonia should ultimately prove to be one of the more frequent causes of diffuse calcific foci in the lungs. In a recent publication Brunton and Moore? surveyed 16,894 people and found 463 or 2.7 percent with a history of chickenpox in adult life. Among these there were eight patients who had diffuse calcification presumed to have been caused by chickenpox pneumonia. This reflected an incidence of 1.7 percent who underwent subsequent calcification. Since eight occurred among approximately 16,000 people in the survey they found approximately one among each 2,000 people in their general population. The average radiologist even in areas where histoplasmosis is endemic does not see more than one patient with diffuse focal calcification per thousand chests examined. It behooves him to check each of these patients to determine whether there was a history of chickenpox in adult life and if the history is positive to rule out other causes. Recently I saw such a patient and confirmed a severe case of chickenpox pneumonia 14 years earlier. This patient had negative tuberculin tests and a negative complement fixation test for histoplasmosis. Our patient was a heavy smoker prior to and after her Varicella pneumonia. Knyvettv" and his associates have raised the question of the relationship of smoking to the formation of calcification in patients who have had Varicella pneumonia. Since smoking is one of the major causes of pulmonary fibrosis it is reasonable to conjecture that the combination of the two processes would be more apt to produce calcification. The vast majority of patients described in the literature who have pulmonary calcification following chickenpox pneumonia have been smokers. It does not, however, seem necessary to have the combination. The late effects of chickenpox pneumonia on pulmonary physiology have recently been investigated by Dahlstrom and his associates" who performed pulmonary function studies on patients who had calcification following Varicella pneumonia. They found signs of increased shunt in the pulmonary circulation in many of their patients and concluded that pulmonary involvement in Varicella may be extensive enough to cause lasting though moderate impairment of respiratory function. The differential diagnosis includes many diseases. Histoplasmosis is the most frequent cause of calcification indistinguishable from those of \1aricella pneumonia. Histoplasmosis, unlike Varicella, frequently results in cal-
CHEST, VOL. 60, NO.5, NOVEMBER 1971
cification in the hilar nodes, spleen and occasionally in the liver. Tuberculosis was once thought to be a frequent cause of diffuse calcification in the lungs hut evidence in favor of miliary calcification in the lung has become less convincing in recent years and is considered extremely rare or nonexistent by many authorities. Coal miners' pneumonoconiosis results in miliary calcifications. These are usually associated with a background which has only minimal fibrosis. Schistosomiasis can cause a similar picture but is associated with cor pulmonale and esophageal varices. Other conditions which cause parenchymal calcification include Caplan's syndrome, scleroderma, amyloidosis, paragonimiasis, armillifer, metastatic neoplasm, pulmonary ossification, pulmonary alveolar microlithiasis and mitral stenosis. I am grateful to Dr. Earl B. Wert and Dr. Thomas D. Davis for their help with the pathology in this case and to Dr. Samuel Eichold for the interesting clinical history. Mrs. Norma Breazeale is C0l11111ended for her help in the preparation of this paper. ACKNOWLEDG~IENT:
REFERENCES
2 3
4 5 6 7
8
9
Mackay JB, Cairney P: Pulmonary calcification following varicella. New Zeal Med J 59:338, 453-457, 1960 Buechner HA: The differential diagnosis of miliary diseases of the lungs. Ann Intern Med 43: 1,89: Ill, 19,159 Abrahams EW, Evans C, Knyvett AF, et al: Varicella pneumonia: A possible cause of subsequent pulmonary calcification. Med J Aust 2:781-783, 1964 Knyvett AF, Stringer RE, Abrahams EW: The radiology of chickenpox lung. J Coli Radiol Aust 9:2, 134-139, 1965 Knyvett AF, Stringer RE, Abrahams EW: Pulmonary calcification following chickenpox in childhood. J Coli Radiol Aust 9:3, 224-227, 1965 Waring JJ, Neubuerger K, Ceever EF: Severe fonns of chickenpox in adults. Arch Intern Med 69:384-408, 1942 Brunton FJ, Moore ~fE: A survey of pulmonary calcification following adult chickenpox. Brit J Radiol 42: 256-2.59, 1969 Dahlstrom G, Hillerdal 0, Nordbring F, et al: Pulmonary calcifications Following Varicella and their effect on respiratory function. Scand J Resp Dis 48:249-267, 1967 Salzman, E, Lung calcifications in x-ray diagnosis. St. Louis, Charles C Thomas, 1968
Reprint requests: Dr. Raider, 1720 Spring Hill Avenue, Mobile, Alabama 36604
Intrathoracic Lipomas* Richard F. Rosenberg, .l1.D., Berta At. Rubinstein, L\t.D.,oO and Neil H. Messinger, u.o»
Two cases of thoracic lipomas are reported, one subpleural and the other both intra- and extrathoracic. Some of the more important roentgen and clinical features are stressed. Lipomas should be considered in the differential diagnosis of pleural tumors. o From
the Department of Radiology, Montefiore Hospital and Medical Center, Bronx. 00 Associate Professor of Radiology, Alhert Einstein College of Medicine. tAssistant Professor of Radiology, Albert Einstein College of Medicine.
508
ROSENBERG, RUBINSTEIN AND MESSINGER
of adipose tissue ill tIll' subpleural paT herietalpresence area was emphasized when Evunder! reported
three case-s of extrupleural fat pads seen with pneumothorax . It would seem likely, therefore, that lipomas. com mon tumors of subcutaneous tissue, should arise fairly Irequentlv in this regioll . I lowcver, a review of the literature shows that iutruthoracic lipomas are rarely encountered, particularly those of subpleural or parietal pleural origin . \\'e have encountered two such cases within the past two years, the second of which was correctly diagnosed preoperatively. CASE REPORTS CASE
I
A 14 and one-half vear-old white h"v first sOIl~ht uu-dical attention lx-cause of ft'\ 't'r , malaise, ami intennittent shaking chills of two and a half weeks ' duration . The past history was unn-markahh-. Physical exa m illation and laboratory data wr-r« unn -veulimr . Houtim- c lu -st film (Fig I) showed all ovoid dt'nsity in the left chest wall in the area of tln- 7th and Stlt inn -rcostul spaces. Oblique views of the chest and laminauruphy cleuumstrutcd th e typical extraph-urul uppeurunc«, as well as SOllie n -lutive radiolucency of th e mass . The mass was noted to lx- mobile and tilt' adjucent ribs wen- intact. At thonu-otomy, a fi x () em tumor was fouml suhph-urally at the lew I of tilt' h-It Hth rih overlapping tilt' 7th and Hth intercosta] span's at tht, posterior a xillary lim " unattachecl to the d,,'st wall. Histolouic sections revealed the pn-scnce of ruaturr- fat ('{,lis consistl'nt with lipoma.
F'(;t:IlE 2. A poorly d,·fined mass is seen on the frontal view overlying tilt' right .')th intercostal space. ( Fig .'3). It was noted to he mohil« and extrupleural in origin (Fig 4). A preoperative radiographic diagnosis of a lipoma was marie. S"hs('I1,,,'ntly tlu- putk-nt 's physician palpate-d a
This usymptumatic patient was found to han' a poorly d(,fil1( 'd mass o\'{,dying the right 4th and .')th intercostal spact·s on routine chest film (Fig 2). On left anterior oblique vii-w, tilt' mass is shown to he hOllr-glass in confiuurution
Fu.tru: I. Frontal \'iI'W showiru; r-xtruph -ural ovoid d, 'nsity in 7th .mcl Sth illtl "Tostal spac,'s.
FI(;l'IlE :3. LAO projection demonstrutr -s tlu- hour-glass configuration of tilt' I,'sion .
CHEST, VOL. 60, NO, 5, NOVEMBER 1971
509
PACEMAKER-INDUCED SUPERNORMAL A-V CONDUCTION
roentgenographic signs to help in the diagnosis of intratboracic lipoma. Gramiak and Koerner, ~ in describing two cases of subpleural lipoma, emphasized the change in the shape of the lesion with respiration . During deep inspiration , there is a Ratten ing and overall diminution in the size of the mass due to compression by expanding lung. Dolley and Brewer" noted that mediastinal lipomas transmit cardiac pulsations with an undulating motion. Heuer" noticed the lucency of the mass. Berne and Heitzman" recognized that localized pleural tumors are often pedunculated. Because of the presence of the pedicle, these tumors are mobile and, hence, marked changes in shape and density of the mass will occur Oil comparable projections. They feel that recognition of pedunculation indicates with certainty that a mass is of pleural origin and, therefore, represents the most reliable sign of a pleural tumor. Although a rare entity, lipomas should be considered in the differential diagnosis of extrapleural masses simulating pleural tumors. Its accessibility, easy removal, and benignity make for rapid, postoperative recovery and excellent prognosis. REFERESCES
2 3 FIGURE 4. Opposite oblique confirms the extra pleural location of the lesion. mass within the soft tissues of tilt' chest wall. In the physician's omct', with local anesthesia, a yellow dumbbell-shaped mass was found in tilt' soft tissues of the chest wall in tilt' region of the fourth anterolateral right rib. The origin of tht' mass was noted to he deep to tilt' intercostal muscles and endothoraclc fascia. Thoracotomy was considered necessary for tilt' total excision of the lesion. Microscopic sections of tilt' removed portion revealed the presence of mature fat cells consistent with a lipoma. DISQ.JSSIO:\,
Most intrathoracic lipomas are discovered on routine chest roentgenograms in asymptomatic patients. Symptoms generally arise when the mass exerts pressure on contiguous structures, Berne and Heitzman- emphasized that intrathoracic masses, when accompanied by fever, chills, migratory arthralgias, and clubbing of digits are likely to be pleural in origin. Despite such symptoms in our first patient, we believe that the tumor was an incidental radiologic finding. Keeley and Vana" classified mediastinal lipomas as : I) intrathoracic, those lying entirely within the thoracic cage; and 2) hour-glass thoracic lipomas, those having an intrathoracic and extrathorucic portion . Case 1 belongs to the first group while Case 2 can be classified as the hour-glass variety. Because the correct preoperative diagnosis has been made rarely, several authors have attempted to develop
CHEST, VOL. 60, NO.5, NOVEMBER 1971
4 5 6
Evander LC: Pleural fat pads. Cause of thoracic shadows . Amer Rev Tuherc S7 :4HS, HJ48 Berne AS, Heitzman ER : The roentgenologic signs of pedunculated pleural tumors. Amer J Hoentgenol Rat! Ther and Nuclear Med 87 :892, 1962 Keeley JL , Vana AJ: Collective reviews : Lipomas of nuxliastinum-1940 to 1955. Internat Ahstr Surg 103:313, 19S() Gramiak R, Koerner HJ : A roentgen diagnostic ohservation in subpleural lipoma. Amer J Hoentgenol Rat! Ther and Nuclear ~led 98 :465, 1966 Dolley FS, Brewer LA III : Diagnosis and treatment of primary intrathoracic hnnors. JA~IA 121: 1130, 1943 Heuer (;J : Thoracic lipomas. Ann Surg 98:801 ,1933
He-print requests : Dr. Neil Messinger, Monteflore Hospital Center, III East 210th Street, Bronx 10467 and ~lt ·dical
Pacemaker-Induced Supernormal Atrioventricular Conduction * Denllis V . Cokkinos, A/.D.;·· Louis L . Leatherman, ,\J. D.;t Roher! D. Leachman, .\ I.D., F.C.C.P.;: and
Robert t. Hall, M .D .§
Atrioventricular conduction occurred intermiUently in a patient paced for complete heart block produced by inferior myocardial infarction. Atrial stimuli were conducted to the ventricles only when they occurred 320 to 360 msec after the spike of the right ventricular endocardial pacemaker. This phenomenon is attributed to the production of supernormal atrioventricular conduction by the pacemaker induced beats. • From the Cardiology Section, Saint Luke's Episcopal Hospital and tilt' Texas Heart Institute, Houston , Texas. •• Fellow in Cardiology, Saint Luke's Episcopal Hospital. t Attending Cardiologist. Saint Luke's Episcopal Hospital. :Chief, Cardiology Laboratory, Saint Luke's Episcopal Hospital and Texas Heart Institute. §Chief, Cardiology Service, SI. Luke's Hospital and Medical Director, Texas Heart Institute.